High Altitude Risks
Suzanne Matthiessen | 3/28/05

 The Post recently received a letter from a local citizen who believed that living at our altitude caused lung and other health problems. It was her opinion that these conditions were a large reason why many people choose to move away, according to her informal surveys of folks having garage and yard sales prior to their return back to lower elevations.

I decided to find out if the numbers and reasons were as high as she thought they were, so I put in a call to the Pagosa Family Medicine Center. While I waited for a call back, I started to do some research on the potential health risks of living at high altitudes. One of the top concerns I've heard being discussed as to why the proposed Village at Wolf Creek development, atop Wolf Creek Pass, should not happen is that living at that high of an altitude (over 10,000 feet above sea level) would be disastrous for the health of the people living there. The person who sent us the letter also voiced her position on these dangers that were not being openly revealed by the Village's developers, so it seemed that is was time to obtain some facts.

First off, let me describe the condition known as Acute Mountain Sickness (AMS) that affects many people when they first arrive at moderate (7000 – 8000 feet) to high altitude (9000 feet and above) locations. Many of us who live here year 'round experienced AMS after we first moved here, and it is a condition that frequently affects our visitors. For some, the symptoms are minor, while others suffer greater, sometimes incapacitating discomfort.

A conference was held during the 1991 Hypoxia and Mountain Medicine Symposium at Lake Louise, Canada to define the various altitude syndromes. This group defined AMS as, "In the setting of a recent gain in altitude, the presence of headache and at least one of the following symptoms: gastrointestinal (anorexia, nausea or vomiting), fatigue or weakness, dizziness or lightheadedness, difficulty sleeping." Shortness of breath was also mentioned. 1
There are many variables that influence if and to what degree a person will experience symptoms of AMS. These include how quickly the person goes from lower to higher altitudes (e.g. if they arrive by plane or automobile) and whether or not they allow themselves to acclimatize gradually, how long they are exposed to high altitude conditions, and the amount of exercise they participate in and how much water they drink when at higher altitudes.

In a large study of tourists visiting Colorado, 71% had at least some symptoms of AMS after arrival at altitudes of 6900-9700 feet above sea level. Symptoms usually abate after the individual becomes acclimated to the area or descends to lower altitudes.1

Concerns at even higher altitudes

Things get more challenging at elevations of 10,000 feet and higher, all due in part to insufficient oxygen for human need coupled with decreased barometric pressure. Beyond the milder effects of AMS, we run into health conditions that have a potentially greater negative long-term impact. Of these, a person can experience high altitude pulmonary edema (HAPE) at 9000 to 10,000 feet, high altitude cerebral edema (HACE) at 10,000-12,000 feet, and high altitude retinal hemorrhage (HARH) at 17,000 feet and above.

Each condition is characterized by the following:

HAPE: shortness of breath during rest and exercise, difficulty breathing while lying down, cough that can lead to vomiting, weakness, chest tightness, mental confusion, headache, coma. The first symptoms of HAPE occur 1-3 days after arrival at higher altitudes. Diagnosis of HAPE must include at least two of the symptoms and signs listed.

HACE: severe headache, staggering gait, hallucinations, stupor. These indicate swelling of the brain.

HARH: visual disturbances, including spots before the eyes. Blood clots and bleeding into the retina occur in 50% of those who go above 17,000 feet.

Not everyone will experience all of these conditions, but their risk increases with lack of physical conditioning, rapid ascent, previous episodes of AMS, chronic illness of any sort (particularly cardiovascular and lung diseases), excess alcohol consumption or use of mind-altering drugs, including narcotics and tranquilizers.2

Eventually, death can occur from the above conditions if they are ignored and not properly treated.

In an extensive study by the International Society for Mountain Medicine, children are also highly susceptible to the harmful impacts of being at very high altitudes. The study determined that children over the age of eight will present altitude illness in the same manner as adults. The study expressed concerns of younger children not being able to accurately verbalize symptoms, with pre-verbal children being the greatest worry. They described the symptoms of altitude sickness in very young children as "increased fussiness, decreased appetite and possibly vomiting, decreased playfulness, and difficulty sleeping," usually presenting beginning four – twelve hours after ascent to altitude. The study also noted there is little data on how well children acclimatize to higher altitudes in comparison to adults. The ISMM study was not able to definitely substantiate increased rates of SIDS (Sudden Infant Death Syndrome), as earlier studies of children living in high altitudes had conflicting results; however, they state that the "possibility of an association warrants careful consideration of an ascent to altitude with a young (under one-year-old) infant."
The IMMS studied also reiterated the fact that chronic cardiopulmonary illnesses in children can also be exacerbated by high altitudes and result in HAPE. 3

The Leadville, Colorado studies

In 1961, Dr. Robert F. Grover, M.D., PhD, Emeritus Professor of Medicine at the University of Colorado, conducted studies to seek evidence of pulmonary hypertension (high blood pressure in the arteries that supply the lungs) in residents of Leadville, Colorado living at an altitude of 10,150 feet, utilizing resources from the Division of Cardiology at the University of Colorado School of Medicine. (Note: Don't let the date cause you to dismiss what Dr. Grover discovered, as it really has no relevance to what his studies revealed.)

A team of residents from the Cardiology Division conducted a clinical survey of the entire student body of Leadville High School that year. Each of the 508 students received a physical examination, their personal health histories were documented, and electrocardiogram and chest x-rays were taken. In many students, the findings were strongly suggestive of pulmonary hypertension.
Further tests were run in February 1962 after these initial results were obtained. Many of the students willingly agreed to heart catheterization tests, which determined that the mean pulmonary artery pressure in the subject group was comparable to what was found in people who lived in at 15,000 feet in the town of Morococha in the Andes mountains of Peru, as per research conducted through Universidad Nacional Mayor de San Marcos in Lima.

Doctor Grover states, "One must realize that while we had documented pulmonary hypertension in vigorous, healthy, asymptomatic young people, altitude-related pulmonary hypertension can be disastrous when combined with some other pulmonary vascular insult, be it polycythemia [an increase in number and concentration of red blood cells] (common in Leadville), sleep apnea, primary pulmonary hypertension, congenital intracardiac left to right shunts or re-entry high-altitude pulmonary edema (HAPE). Further, we now know that when someone is born and lives at high altitude, the lung circulation has an entirely different and rather threatening behavior when faced with the additional challenge of chronic hypoxia [decreased oxygen to body tissue]." 4

A Pagosa medical professional's expertise

At this point, Dan Keuning, Nurse Practitioner with the Pagosa Family Medicine Center returned my call. I told him about what I'd learned so far, and asked for his input. He was very happy I was doing this story.

Although he did not concur with the estimations of the number of people leaving Pagosa due to health conditions guessed by the person whose letter prompted this story, he agreed that there exists the problem of Chronic Mountain Sickness (CMS), an illness that is a complication that represents failure to recover from AMS over a long period of time. Symptoms of CMS include shortness of breath, fatigue, bloated face and body, and the rare possibility of congestive heart failure after years of living at high altitude.
"We have issues of people moving here that are very healthy at lower altitudes and then they come here and develop health problems because of very minor lung problems or breathing problems that get much worse with altitude, so that's a fact. I also think of the percentages of people who have heart disease that are doing very well at a lower altitude but come up here and don't do so well. Your blood pressure between sea level to here can go up to fifteen points higher, so that makes blood pressure [problems] worse," Keuning said.

I then brought up the subject of the proposed Village at Wolf Creek, and the health problems I listed above that would result at living at that altitude.

"The developers are crazy to think they're going to have a village at 10,500 feet with anybody living there year 'round," Keuning said emphatically, "especially anybody with any type of chronic illness. Chronically you'd end up getting high mountain polycythemia, an overproduction of red blood cells to compensate for the lack of available oxygen. And so basically it thickens your blood. We have a little bit of that at this altitude, especially those of us who work out and run. Our bodies compensate and we do fairly well; our hemoglobin levels are higher than they would be at sea level. But at even higher altitudes it can cause real problems."

Keuning wrote an article in 2001 for Colorado Outdoors magazine for their special fall hunting guide on the health dangers of coming to high altitudes while he was working as deputy coroner for Archuleta County. In the article, Keuning tells the story of one hunter who died down at the southern end of the county near the New Mexico border in October 1999. The hunter was up at 11,000 feet at Banded Peaks, and according to friends who were with him at the time of his death, had been suffering from HAPE for several days, but was determined to bag the elk he'd been trailing that morning. Although he killed the elk, ignoring his symptoms of HAPE cost him his life.

"This very sad scenario plays out too many times in the mountain communities of Colorado and other mountain states," Keuning says in the article. "Altitude illness should not be taken lightly. Altitude affects everyone to some degree." 5

A moral situation

I told Keuning I did not understand why the proposed Village at Wolf Creek developers are apparently not informing potential buyers about the health problems they could incur from living at the top of Wolf Creek Pass. I wondered out loud that if it did get built, would the developers face lawsuits by their omission of information about such life-affecting conditions before a person signed on the dotted line if someone died just like the hunter did?
I also expressed my concerns that even short-term visitors who'd be lodging up at the proposed Village instead of down in Pagosa could be in danger, especially with the likelihood of alcohol consumption by many visitors and the fact that sleeping at above 10,000 feet increases the risks of HAPE.

Keuning agreed, and then added his comments on the subject of the obligations of informing people who are considering moving to places like Pagosa—or even higher altitudes—of the potential health risks.

"You could say the same thing about Pagosa right now. I mean, we've got people who have moved here who have had to sell their house within the first year of moving here because they haven't been able to tolerate it [the conditions and the negative health impacts]. They ask when they come in for medical help, 'Why didn't my realtor tell me?' But if you make an $18,000 commission off of something, people are a lot more hesitant to tell the truth when money is involved," Keuning said.

1. "Altitude-Related Disorders," James D. Anholm, MD, Chief of Pulmonary Section, Jerry L. Pettis Memorial Veterans Affairs Medical Center, Associate Professor of Medicine, Department of Medicine, Section of Pulmonary and Critical Care, Loma Linda University, http://www.emedicine.com/, October 7, 2004.
2. "Altitude Illness," From Complete Guide to Symptoms, Illness & Surgery by H. Winter Griffith, M.D., Putman Publishing Group, posted on MDAdvice.com.
3. "Children at High Altitude: An International Consensus Statement by an Ad Hoc Committee of the International Society for Mountain Medicine, March 12,2001," Pollard, Niermeyer, Barry, et al., High Altitude Medicine and Biology, Volume 2, Number 3, 2001, Mary Ann Liebert, Inc.
4. "'You Won't Find Anything'," Robert F. Grover, M.D., Ph.D., published on The American Thoracic Society Website: www.thoracic.org.
5. "The High Altitude Factor," © Dan Keuning RN, MSN, FNP, Colorado Outdoors 2001 Hunting Guide.


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